For a period near the end of my contract, my job was to increase the English level of a group of Chinese nurses, ostensibly to prepare them adequately for university in Australia where they would undertake a nursing conversion course one of many precarious steps on the way to becoming a registered nurse in Australia. The group of nurses I taught over an eight-week period consisted of up to twenty four students; all but one later made it to Australia to begin their course at a major university.
Needing them to use their English, I used topics that they knew something about and had an interest in, which included discussions on the work situation for nurses in China, and several essays they wrote about issues in the Chinese health system. I knew that I was unlikely ever to gain access to the inner happenings of hospitals in China personally and I thought it was unlikely that the Chinese media would provide me with much insight either, so I was very interested to listen to and learn about, what they had to say. It was through these interactions that I realised how complicated and inadequate the Chinese Health system is, an understanding that prompted me, before writing this article, to do additional research and reflect on discussions with others.
The corruption in China is one of the many things that quickly became apparent to me about the culture. While in the country, I talked to a lot of people about it who consistently claimed that it is very common in just about any area you can imagine; perhaps surprisingly, even the TV news seemed to validate this contention with intermittent reports of officials and business people in various positions of power being caught after taking sizable bribes for some unseemly deed or laundering money one way or another. In this context, it would come as no surprise to anyone familiar with all of this that the medical system appears to be no exception. One of the undisputed claims made by the nurses to this effect was that doctors routinely receive illegal money from patients, which increases their income substantially from that of their already, relatively high salaries. As a consequence, the patients who can afford this expect to receive better treatment and/or to be allowed to queue jump, receiving treatment sooner than they otherwise would. The nurses know this happens, the patients that pay evidently know it happens, many people claim that everyone knows it happens, and as government officials are sometimes patients themselves and can be presumed to have friends and acquaintances that are medical staff or patients from time to time, it can probably be safely assumed that the knowledge of this phenomenon is also widespread in the government. Notwithstanding the relatively high profile of this phenomenon, as far as the nurses are concerned it continues unimpeded.
Interestingly, they made the claim that, while the doctors gain extra for the services provided, the nurses themselves, without any additional financial reward, have to provide or assist in delivering much of this additional or special treatment, despite their knowing about the situation. Just as disturbingly, the doctors are said to have a tendency to prescribe medications from which they receive greater financial reward and which is attributed to their having special relationships with drug companies. They are claimed to have this bias regardless of the effectiveness and applicability of the medications, or the unnecessary added expense to the patient. Unsurprisingly, the nurses are sometimes the ones who have to administer these medications, fully aware of the situation but being unable to say anything to the patients, their supervisors, or report it to anyone else because of their need to protect their jobs, due to the ever present problem of possible corruption and complicity of those in higher positions. Thus, they simply keep quiet and do their work.
As in other areas, nursing contracts come with breach penalties which, despite being understandable in some respects, are notorious for putting employees in a vulnerable position. In the case of the Chinese nurses, they suffer the threat of having to pay or lose thousands of Yuan just to leave their job, an amount which could be equivalent to one or more months' salary, sometimes much more: I know one nurse who had to pay 20,000 Yuan to leave her job, about six months' salary. Nurses may also be required to pay a deposit before starting work; in one hospital this was 3,000 Yuan, about one month's salary and if they break the contract early without giving one month's notice, they will lose this and, regardless, if they received special education and training provided by the hospital, which sometimes happens, they will have to pay the tuition fee back when breaking the contract. Also, the breach penalty can apply if the hospital administration decides to fire a nurse for whatever reason. Despite these aspects being stipulated in contracts and employees hopefully being aware of them when they sign, problems can arise when the situation in the work place turns for the worse. This is borne out by the nurses' claim that they feel as though they have to be very careful in the way they deal with others in workplace relationships because of the power of those in high positions to influence or determine the fate of those below them, part of this includes the need to be submissive to the demands of their superiors and the doctors they work with, even including unwanted attention that they may be given by them, some of which would commonly be called sexual harassment.
In order to keep their jobs they must work when they are told to work with little or no negotiation. As a result, many work overtime without additional pay; in some cases they need to work many hours of overtime on a near ceaseless basis, without any hope of relief and, once again, there is nowhere for them to turn for assistance, which is said to lead to much stress, physical problems, and burnout.
Their vulnerability also includes the reporting of medical incidents such as needle pricks. Nurses are formally required to report any incident, but there is little benefit or incentive in it for them to do so, as they will be made to take weeks off, reportedly sometimes without pay and wait until the results of the tests become available to determine if they are infected with anything or not. If they are infected, they may be unable to continue to work in the profession but, in the cases in which they will lose their source of income for the period, they may not be able or want to afford this.
The problem that a system like this creates is that statistically there will always be those who move through it with relative ease and success, but there will also be those who become targets of others and suffer through unfortunate events, the terrible consequences of which are imaginably many. Moreover, such a system relies on people in power and with responsibilities being good and honest, and this, in an unchecked and visibly corrupt environment, is not a sound assumption to make.
Adding to the stress of both doctors and nurses is the stated constant threat of physical abuse, which weighs heavily on their minds. They claim that patients and families, on occasions, attack them, and when they are spoken to aggressively, the possibility that the situation could turn violent understandably causes considerable angst. Also, there is claimed to be, all too often, inadequate security personnel in the hospitals or none at all. Some nurses said that in their hospitals, where staff routinely suffered physical abuse and when they need assistance, they contact the local police station which sends officers around but, before they arrive, the nurses and other hospital staff have to deal with the situation themselves. The potential for an incident to get out of control before adequate and trained reinforcements arrive in such situations is evident.
Moreover, the lack of security in hospitals continues despite hospital administrations' knowledge about the frequent occurrence of physical abuse. Interestingly, the suggested cause of such threats and attacks is that the patients and families form the belief that the doctors and nurses are not doing all that they can to help the patient concerned. An important factor that is considered to have created this situation is the increasing medical costs over the last few decades and the concomitant rising living standards. Perhaps insightfully, the nurses claimed that the rate of attacks correlates positively with these changes because of the heightened sense of entitlement and expectation that can be readily thought to go with having more economic power in a developing China, which acts in combination with the pressure that such expensive medical treatment puts on the economic resources and the emotions of families. The rationale is that they pay so much for their medical treatment that they become angry if the patient does not return to good health fast enough, to the desired or expected degree, or at all. This kind of thinking treats medical services as a product to be purchased and delivered without exception and thus failure to deliver is intolerable.
Such a circumstance would seemingly be enabled by relative ignorance of the complexities of medical procedures and the probabilities and risks associated with many forms of treatment that are currently available; a public awareness issue that the profession and medical staff everywhere constantly need to struggle with, but which is perhaps a more severe problem in China where the level of education is quite low and the size of the population so large, making education campaigns aimed at raising the general level of awareness of the population all the more difficult to achieve and sustain.
In addition to these frustrations is the claim that many nurses are required to do accounting work and menial jobs such as cleaning; roles that evidently diverge from, and do not take advantage of, their scientific and clinical knowledge and skill set, and significantly, adds further strain to the ratio of nurses available in clinical settings, a ratio of nurses per bed in hospitals, and per person in the general population, that is already relatively low internationally and which is known to have deleterious outcomes for patients. The nurses suggest that the hospital administrations either lack the willingness or the finances to employ an appropriate number of nurses and other staff for the proper functioning of the hospital.
However, in an apparent attempt to ameliorate this issue, when a perceived need arises, less-qualified and cheaper temporary workers with less education and training are often employed as "substitutes" to fulfil part of the auxiliary functions of nurses. Notwithstanding, the hospital administrations are reported as preferring to employ doctors where possible rather than nurses, because doctors are believed to draw money to the hospitals, as long as the demand exists, through being able to take on a patient case load of their own. This preference is suggested to be taken to the point of creating an ineffective ratio of doctors to nurses, which has the consequence of sustaining the poor ratio of nurses to patients. This staffing issue which, coupled with the claim that there are many unemployed nurses, allows us to reframe the stated nursing shortage in the country. Perhaps unsurprisingly, in such a context, part of the nursing shortage relates not just to the number of nurses actually available for work, but also to a bias for revenue optimisation and the associated preferences for the commitment of limited capital.
In addition to these professional and systemic issues, and exacerbating nurses' experience is the stated perception that they are considered to have a low status, not just in the hospitals, but also in society generally. In the hospital setting they suggest this is particularly evident when they interact with patients and their families who treat them with less or little respect, despite their significant, hands-on contribution to the treatment of many patients, which contrasts with the often aloof and absent doctors throughout a patient's time spent in hospital.
With perspectives such as these just under the surface and so ready to be articulated, is it any wonder so many nurses want to leave China and are doing so in large numbers? The magnitude of the perceived differences in the nursing environments between China and those abroad, real or imagined, and the intractability of the problems in their own health system provides nurses with the impetus to seek better conditions elsewhere, which evidently compounds the country's shortage of nurses. However, the next question is whether they will fair better elsewhere professionally and socially, and if so, by how much?
Feeds